Provider Demographics
NPI:1780877373
Name:WILDROSE HOME HEALTH SERVICES, INC.
Entity type:Organization
Organization Name:WILDROSE HOME HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-625-8938
Mailing Address - Street 1:18396 568TH AVE
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6649
Mailing Address - Country:US
Mailing Address - Phone:507-625-8938
Mailing Address - Fax:507-625-9038
Practice Address - Street 1:1021 N RIVERFRONT DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3341
Practice Address - Country:US
Practice Address - Phone:507-625-8938
Practice Address - Fax:507-625-9038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
MNNA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN003610200Medicaid